Final Revision Flashcards
(138 cards)
1
Q
Proper tooth removal:
A
- does not require a large amount of strength
- the tooth should not be pulled from bone
- it is gently lifted from its socket
- controlled force in a manner
2
Q
Excessive force may:
A
- injure local soft tissue
- damage the surrounding bone and teeth
- fracture the crown
- make the extraction more difficult
- increase the patient’s intraoperative and postoperative discomfort and anxiety
3
Q
SOS
local anesthesia:
even with profound LA patients will still experience discomfort from:
A
- is required to prevent pain during extractions
- eliminates sensation from the pulp, periodontal ligament, and adjacent soft tissues
-patients will still experience discomfort from pressure placed on the TOOTH, surrounding tissues, and JAW JOINTS during most extractions
4
Q
The surgeon must remember that the patient will need to distinguish between:
A
sharp pain and the dull feeling of pressure when determining the adequacy of anesthesia
-it is difficult
5
Q
SOS
INDICATIONS FOR REMOVAL OF TEETH:
A
•Caries
- most common
- The extent to which the tooth is carious and is considered non-restorable is a judgment call to be made between the dentist and patient
•Pulpal Necrosis
-result of a patient declining endodontic treatment or
of a root canal that is tortuous, calcified, and untreatable by standard endodontic techniques
•Periodontal Disease
- excessive bone loss and irreversible tooth mobility found
- HYPERMOBILE teeth should be extracted
•Orthodontic Reasons
- orthodontic correction of crowded dentition with insufficient arch length
- most commonly extracted teeth are the maxillary and mandibular premolars but also mandibular incisors
•Malposed Teeth
- If they traumatize soft tissue and cannot be repositioned by orthodontic treatment
- maxillary third molar, which erupts in severe buccal version and causes ulceration and soft tissue trauma of the cheek
- hyper-erupted because of the loss of teeth in the opposing arch
•Cracked Teeth
- cracked crown or a fractured root
- can be painful and is unmanageable by a more conservative technique
- sometimes cracked teeth have already undergone endodontic therapy in the past
•Impacted Teeth
-if a partially impacted tooth is unable to erupt into a functional occlusion because of inadequate space, interference from adjacent teeth, etc
•Supernumerary Teeth
- are usually impacted
- may interfere with eruption of succedaneous teeth and have the potential for causing their resorption and displacement
•Teeth Associated with Pathologic Lesions
- odontogenic cysts
- the tooth or teeth can be retained and endodontic therapy performed
•Radiation Therapy
- removal of teeth that are in the beam of radiation therapy
- however, many of these teeth can be retained with proper care
•Teeth Involved in Jaw Fractures
- patients who sustain fractures of the mandible or the alveolar process
- if the tooth is injured, infected, or severely luxated from the surrounding bony tissue or interferes with proper reduction and fixation of the fracture !!
6
Q
SOS
CONTRAINDICATIONS FOR REMOVAL OF TEETH
A
SYSTEMIC:
-Uncontrolled leukemia and lymphoma
•infection as a result of non-functioning white cells and
•excessive bleeding as a result of an inadequate number of platelets
-Uncontrolled Cardiac diseases: severe myocardial ischemia such as UNSTABLE ANGINA PECTORIS and
patients who have had a RECENT MYOCARDIAL INFRACTION
-Malignant hypertension
-Uncontrolled cardiac dysrhythmias
-Pregnancy: middle trimester safe
-Variety of medications usage (caution needed)
LOCAL:
- History of therapeutic radiation for cancer: extractions performed in an area of radiation may result in osteoradionecrosis, and therefore, the extraction must be done with extreme caution
- Teeth that are located within an area of Tumor !!!!!!!!!
Acute infection is NOT a contraindication to extraction but it may be difficult to extract b/c:
•the patient may NOT ABLE FOR WIDE OPEN MOUTH
•it may be DIFFICULT TO REACH a state of PROFOUND LA
7
Q
Access to the Tooth - Examine:
A
- the extent to which the patient can open the mouth
- the location and position of the tooth to be extracted within a dental arch
- the condition of the crown •If large portions of the crown have been destroyed by caries, the likelihood of crushing the crown during the extraction is increased, thus causing more difficulty in removing the tooth
- large amalgam restorations (produce weakness in crown)
the forceps are applied as far apically as possible to grasp the root portion of the tooth instead of the crown for such conditions
ALSO
-the condition of adjacent teeth
8
Q
If adjacent teeth have large restorations, the surgeon should use:
A
elevators with extreme caution because fracture or displacement of the restorations may occur
The patient should be informed before the surgical procedure about possible damage to these restorations during the process of obtaining informed consent.
9
Q
SOS
It is essential that proper radiographs be taken of any tooth to be removed
periapical radiographs:
panoramic radiographs:
a) Radiographs should probably be retaken before surgery when they are taken..:
b) Radiographs taken for mandibular premolars should always include:
A
periapical radiographs:
information concerning the tooth, its roots, and the surrounding tissue
panoramic radiographs:
for impacted teeth as opposed to erupted teeth
- adequate penetration and good contrast
- properly positioned so that it shows all portions of the crown and roots of the tooth under consideration without distortion
- the relationship of the root structures of adjacent teeth must be known (be careful if adjacent roots are close to the root being removed)
a) older than 1 YEAR should probably be retaken before surgery
Radiographs that are taken, but not available during surgery, are of limited value
b) MENTAL FORAMEN
10
Q
inferior alveolar canal in relationship with the roots of mandibular molars:
A
- Such extractions may lead to injury of the canal and cause damage to the inferior alveolar nerve
- CBCT images are often useful in these circumstances
11
Q
The first factor to evaluate in radiographic assessment of the tooth to be extracted is
A
the number of roots on the tooth to be extracted
-is known before the tooth is extracted, an alteration in the plan can be made to prevent fracture of any additional roots
must know
- the curvature of the roots and the degree of root divergence
- the shape of the individual root (long roots with severe and abrupt curves or hooks at their apical end are more difficult lo remove)
- the size of the root (short roots are easier to remove)
- evidence of hypercementosis (aging effect)
- evidence of caries extending
- internal or external root resorption
- evaluation of previous endodontic therapy (there may be ankylosis or the tooth root may be more brittle)
12
Q
The principle of universal precautions states that:
A
all patients must be viewed as having blood-borne diseases that can be transmitted to the surgical team and other patients
- To prevent this transmission, surgical gloves, surgical mask, and eye wear with side-shields are required
- the surgical team should wear long-sleeved gowns, which should be changed when they become visibly soiled
13
Q
SOS
for successful completion of the extraction - critical are:
It allows the surgeon to keep the:
A
The positions of the patient, the chair, and the operator
•The best position is one that is comfortable for the patient and surgeon, and allows the surgeon to have maximal control of the force that is being delivered to the patient’s tooth through the elevators and the forceps
The correct position allows the surgeon to keep the ARMS CLOSE TO THE BODY AND PROVIDES STABIITY AND SUPPORT
- It allows the surgeon to keep the wrists straight enough to deliver the force with the ARMS AND SHOULDER and not with the fingers or hand
- The force delivered can be controlled in the face of sudden loss of resistance from a root or fracture of the bone
14
Q
Position errors
The most common error dentists make in positioning the dental chair for extractions is to have
Another frequent positioning problem is for the dentist to
A
- the chair too high
- lean over the patient and put his or her face close to the patient’s mouth
This forces the surgeons to operate with their shoulders raised, thereby making it difficult to deliver the correct amount of force to the tooth being extracted in the proper manner
It is also tiring to the surgeon
15
Q
SOS
For a maxillary extraction, the chair should be _ so that maxillary occlusal plane is _:
The height of the chair should be such that patient’s mouth is:
A
tipped backward
the maxillary occlusal plane is at an angle of about 60 DEGREES TO THE FLOOR
The height of the chair should be such that patient’s mouth is AT OR SLIGHTLY BELOW OPERATOR’S ELBOW LEVEL
maxillary right quadrant:
patient’s head should be turned toward the operator
maxillary anterior arch:
patient should be looking straight ahead
maxillary left quadrant:
patient’s head is turned slightly toward the operator
16
Q
For a mandibular extraction:
the chair should be:
the occlusal plane should be:
A
in a more upright position so that when the mouth is opened wide, the occlusal plane is parallel to the floor
surgeon’s arm inclined downward to a 100 degree angle at the elbow
right posterior teeth:
patient’s head should be turned acutely toward the surgeon
left posterior teeth:
surgeon should stand in front of the patient, but the patient’s head should not turn so acutely toward the surgeon
anterior region:
surgeon stands at the side of the patient, who looks straight ahead
-Some surgeons prefer to approach mandibular teeth from a posterior position (left hand supports the mandible but it requires that the forceps be held opposite the usual method)
17
Q
Sitting position for maxillary extractions
A
patient is positioned in a semi-reclining position
(similar to that used when the surgeon is standing)
patient should be lowered as far as possible so that the level of the patient’s mouth is as near as possible to the surgeon’s elbow
maxillary anterior and posterior teeth are similar to standing extractions - patient is reclined back 60 degrees
-surgeon can work from the front of the patient or from behind the patient
•It should be noted that the surgeon and the assistant have hand and arm positions similar to those used when the surgeon is in the standing position
18
Q
Preparation for Extraction - Patients
A
a minimal draping with a sterile drape placed across the patient’s chest
19
Q
For extraction of the mandibular teeth the surgeon should stand from:
right posterior and anterior teeth:
left posterior teeth:
A
from behind
from front
20
Q
The approach from behind gives the surgeon
A
great visibility of the extraction site and it allows the surgeon to be in a comfortable and stable position
21
Q
mechanical principles and simple machines:
A
- the lever
- the wedge
- the wheel and axle
22
Q
Elevators are used primarily as:
An example of the use of a lever to remove a tooth:
Levers example - used as:
A
as levers
•A lever is a mechanism for transmitting a modest force-with the mechanical advantages of a long lever arm and a short effector arm—into a small movement against great resistance -The first-class lever transforms small force and large movement to small movement and large force
-used as a STRAIGHT ELEVATOR
23
Q
SOS
Wedge
The beaks of the forceps act as _ to expand alveolar bone and displace the tooth in the occlusal direction
A
- The beaks of extraction forceps are usually narrow at their tips and they broaden as they go superiorly
- When forceps are used, a conscious effort must be made to force the tips of the forceps into the periodontal ligament space at the bony crest to expand the bone and force the tooth out of the socket
The beaks of the forceps act as WEDGES to expand alveolar bone and displace the tooth in the occlusal direction
The wedge principle is also useful when a STRAIGHT ELEVATOR is used to luxate a tooth from its socket
An elevator is wedged into the periodontal ligament space, which displaces the root toward the occlusion and out of the socket
24
Q
wheel and axle
A
triangular, or pennant-shaped elevator
When one root of a multiple-rooted tooth is left in the alveolar process, the pennant-shaped elevator Cryer is positioned into the socket and turned
HANDLE serves as the AXLE
ELEVATOR acts as a WHEEL
25
The primary instruments used to remove a tooth from the alveolar process are
what is their use?
- Elevators:
- Forceps:
the elevator and extraction forceps
* Elevators help in the luxation of a tooth
* Forceps help in the bone expansion and disruption of periodontal attachments
26
Forceps can apply five major motions to luxate teeth and expand the bony socket:
```
First, apical pressure
Second, buccal pressure
Third, lingual or palatal pressure
Fourth, rotational pressure
Fifth, tractional force
```
27
*SOS*
Apical pressure of the forceps on the tooth during extraction causes:
BONY EXPANSION
-the center of rotation of the tooth is displaced apically
28
*SOS*
The chance of fracturing the root apex during extraction increases if:
the center of rotation is HIGH and a LARGE amount of force is placed on the apical region of the tooth
29
*SOS*
Buccal force:
Excessive force can fracture:
Buccal pressures result in expansion of the buccal plate, particularly at the crest of the ridge
Excessive force can fracture BUCCAL BONE or cause a fracture of the APICAL PORTION OF THE ROOT
30
Lingual or palatal pressure
is similar to the concept of buccal pressure but is aimed at expanding the linguocrestal bone and,
at the same time, AVOIDING EXCESSIVE PRESSURES ON BUCCAL APICAL BONE
31
*SOS*
Rotational forces/pressures:
useful for which roots?
rotates the tooth, which causes some internal expansion of the tooth socket and tearing of periodontal ligaments
Teeth with single, CONICAL ROOTS and those with roots that are not curved are most liable to luxation by this technique
Teeth that have other than conical roots or that have multiple roots—especially if those roots are curved—are more likely to fracture under this type of pressure
32
tractional forces
useful for delivering the tooth from the socket once adequate bony expansion is achieved
Teeth should not be pulled from their sockets
33
*SOS*
Buccal Vs Palatal bone and the forces applied on maxillary teeth:
Because maxillary buccal bone is usually thinner and palatal bone is a thicker cortical bone
-maxillary teeth are usually removed by STRONGER BUCCAL FORCES and less strong palatal forces
34
*SOS*
In the mandible incisors, canines, and premolars are removed with what force?
In the mandible molars are removed with what force?
strong buccal force and less strong lingual pressures
STRONG LINGUAL PRESSURE first
35
*SOS*
Closed technique extraction:
- also known as:
- used when:
Open technique extraction
- also known as:
- used when:
Closed:
- most frequently used, with any type of surgery
- also known as: ROUTINE TECHNIQUE
Open:
- also known as: surgical/flap technique
- used when: excessive force needed, a substantial amount of the crown is missing or covered by tissue or when access to the root of a tooth is difficult
* The correct technique for any situation should lead to an atraumatic extraction
* the wrong technique commonly results in an excessively traumatic and lengthy extraction
36
3 fundamental requirements for a good extraction
(1) adequate access and visualization of surgery field
(2) a free pathway for the removal of the tooth, and
(3) the use of controlled force to luxate and remove the tooth
37
For the tooth to be removed from the bony socket, it is usually necessary to:
- expand the alveolar bony walls to allow the tooth root a free pathway
- tear the periodontal ligament fibers that hold the tooth in the bony socket
-with the use of elevators and forceps as levers and wedges with steadily increasing force
38
5 general steps to make the closed extraction procedure:
* Step 1 involves loosening of the soft tissue attachment from the cervical portion of the tooth
* Step 2 involves luxation of the tooth with a straight elevator entered perpendicular to tooth
* Step 3 involves adaptation of the forceps to the tooth
* Step 4 involves luxation of the tooth with forceps
* Step 5 involves removal of the tooth from the socket
39
The purpose of loosening the soft tissue from the tooth is twofold:
(1) it allows the surgeon to ensure that profound anesthesia has been achieved
2) soft tissue is loosened to allow the elevator and tooth extraction forceps to be positioned more apically, without interference from the gingiva
40
Elevator blade position:
- the inferior portion of the blade:
- the superior portion of the blade:
- the inferior portion of the blade rests on the alveolar bone
- the superior portion of the blade is turned toward the tooth being extracted
-Strong, slow, forceful turning of the handle moves the tooth in a posterior direction, which results in some expansion of alveolar bone and tearing of the periodontal ligament
41
if the patient does not have a tooth posterior to the tooth being extracted or if it is broken down to an extent that the crowns do not inhibit movement of the tooth, the elevator can be turned in the:
in the opposite direction and more vertical displacement of the tooth will be achieved, which can possibly result in complete removal of the tooth
42
Forceps beaks position:
which beak is situated first?
The lingual beak is usually seated first and then the buccal beak
-Care must be taken to confirm that the tips of the forceps beaks are beneath the soft tissue and not engaging an adjacent tooth
43
Forceps handles are grasp at their:
ends to maximize mechanical advantage and control
44
If the tooth is malposed in such that the usual forceps cannot grasp the tooth without injury to adjacent teeth, which forceps should be used?
other forceps with narrower beaks
45
*SOS*
The beaks of the forceps must be held:
parallel to the long axis of the tooth
46
The left hand is responsible for:
- reflecting the soft tissues of the cheeks, lips, and tongue to provide adequate visualization of the area of surgery
- helps to protect other teeth from the forceps, should release it suddenly from the tooth socket
- helps to stabilize the patient's head during the extraction process
47
The assistant helps the surgeon to:
- visualize and gain access to the operative area by reflecting the soft tissue of the cheeks and tongue so that the surgeon can have an unobstructed view of the surgical field
- suction away blood, saliva, and the irrigating solutions used during the surgical procedure
48
*SOS*
For maxillary left anterior teeth the:
left index finger of the surgeon should:
left thumb of the surgeon should:
the left index finger of the surgeon should REFLECT LIP AND CHEEK tissues
the thumb should rest on the palatal alveolar process
49
*SOS*
Maxillary incisors extraction:
Alveolar bone is:
Expansion of alveolar process will be:
steps:
Alveolar bone is thin on the labial side and heavier on the palatal side
-The forceps are seated as far apically as possible for all extractions
Expansion of alveolar process will be in LABIAL direction
```
steps:
luxation is begun with labial force
slight palatal force is used
rotational
tractional movement
```
50
Rotational movement should be minimized for the:
lateral incisor
51
*SOS*
Maxillary canines extraction:
The initial movement is:
The INITIAL movement is APICAL and THEN to the BUCCAL aspect, with return pressure to the PALATAL
Then delivered in the labial-incisal direction with a slight rotational force
52
If root fracture does occur, a mobile root tip can be removed more easily than:
one that has not been well luxated
53
Maxillary premolars extraction:
The initial movement is:
The initial movement is apical and then to the buccal aspect, with return pressure to the palatal, rotational and last is tractional movement
-for first premolars: no rotational force due to 2 roots!!!
54
*SOS*
Maxillary molars extraction:
which molar is more easily extracted?
The dentist must minimize palatal force because this is the force that fractures the:
for maxillary first molar is preferable to fracture which root?
use strong buccal and palatal pressures, with stronger forces toward the buccal than toward the palate
no rotational force due to 3 roots
second molar is more easily extracted than first molar
-the erupted third molar is also frequently extracted by the use of elevators alone
The dentist must minimize palatal force because this is the force that FRACTURES PALATAL ROOT
preferable to fracture a BUCCAL ROOT rather than a palatal root
55
periapical lesion or debris:
a) If a periapical lesion is visible on the preoperative radiograph and there was no granuloma attached to the tooth when it was removed, the periapical region should be:
b) If any debris is obvious then:
The socket should be debrided only if necessary
If neither a periapical lesion or debris is present, the socket should not be curetted
If teeth were removed because of periodontal disease, there may be an excess granulation tissue around the gingival cuff.
If this is the case, special attention should be given to removing this granulation tissue with a curette, tissue scissors, or a hemostat
the bone should be palpated through the overlying mucosa to check for any sharp, bony projections
a) be curetted with a periapical curette to remove the granuloma or cyst
b) it should be gently removed with a curette or suction tip
56
*SOS*
Initial control of hemorrhage after tooth extraction is achieved by use of:
BITE a GAUZE placed over the extraction socket AT LEAST 30 MIN (not to chew)
the patient closes their teeth together, it fits into the space previously occupied by the crown of the tooth
Biting of teeth together places pressure on the gauze, and the pressure is then transmitted to the socket. This pressure results in hemostasis
57
Extraction movements for maxillary teeth:
incisors:
canines:
premolars:
molars:
incisors and canines:
- apically
- buccally
- palatally
- rotational
- retraction
premolars:
1st: same
2nd: same but without rotation
molars: same but without rotation
58
Extraction movements for mandibular teeth:
incisors:
canines:
premolars:
molars:
incisors and canines:
- apically
- buccally
- lingually
- retraction
premolars: same but with rotational movement (ONLY LOWER PREMOLARS)
molars:
1st: same as anteriors
2nd and 3rd:
-apically
-lingually
-buccally
-retraction
59
*SOS*
Mandibular Teeth extraction:
index finger:
second finger:
thumb:
INDEX finger: BUCCAL VESTIBULAE -retracts cheek
second finger: L vestibulae -retracts tongue
thumb: below chin -for support during extraction
the need lo support the mandible replaces the need to support the alveolar process
60
Mandibular Teeth extraction:
anterior teeth bone:
incisors:
canines:
Alveolar bone that overlies incisors and canines is thin on the labial and lingual sides
Bone over the canine may be thicker, especially on the lingual aspect
61
*SOS*
Mandibular Teeth extraction:
Premolars bone:
Molars bone:
premolars are among the easier teeth to remove
the overlying alveolar bone is THIN on BUCCAL aspect and HEAVIER ON LINGUAL side
the roots of the first molar more widely divergent
than those of the second molar
Linguo-alveolar bone around the second molar is
thinner than the buccal plate, so the second molar can be removed more easily with stronger lingual pressure than buccal pressure
62
Hepatitis B and D viruses are spread by:
by contact with any human secretion
Hepatitis B virus has the most serious risk of transmission for unvaccinated surgeons, their staff members and their patients
63
The staff should continue to wear these protective devices when:
when cleaning instruments and when handling specimens from patients
64
*SOS*
Sterilization =
Antisepsis =
Clean =
antiseptics Vs disinfectants:
Sanitization =
Decontamination =
STERILIZATION = a process that results in the COMPLETE ABSENCE of microorganisms, including bacteria, viruses and bacterial spores
Antisepsis = a process that results in the absence of most pathogenic microorganisms. However, some bacteria, viruses and spores may still be present
Clean = a reduction in the total bacterial count
antiseptics are applied to living tissue, whereas disinfectants are designed only for use on inanimate objects
SANITATION = the reduction of the number of viable microorganisms to levels judged safe by PUBLIC HEALTH STANDARDS
Decontamination = similar to sanitization, except that it is not connected with public health standards
•The chain of sterility is less secure in an office environment, and antibiotics tend to be used more frequently, and often prophylactically
65
Chemical and physical agents:
* Antiseptics, disinfectants, and ethylene oxide gas are the major chemical means of killing microorganisms on surfaces
* Heat, irradiation, and mechanical dislodgment are the primary physical means of eliminating viable organisms
The microbes have variable ability to resist chemical or physical agents
66
*SOS*
The three methods generally available for instrument sterilization are:
•dry heat
ADV: easy to use and unlikely to damage heat-resistant instruments
DISADV: time necessary and the potential damage to heat sensitive equipment
-for handpieces
-lubrication before sterilization
-if the drying phase is not complete, metal instruments such as osteo-tomes and chisels can tarnish, corrode or rust
-boiling in water does not destroy bacterial spores or viruses and is therefore ineffective sterilization technique
•MOIST HEAT
ADV: MORE EFFICIENT AT LOWER TM, LESS TIME and relative availability of office-proportioned autoclaving equipment
DISADV: tendency to dull and rust instruments and cost of autoclaves
•ethylene oxide gas
-At 50°C within 3 hours
-However because it is highly toxic to tissues,
equipment exposed to ethylene oxide must be ventilated
•for 8 to 12 hours at 50°C to 60°C,
•or at ambient temperatures for 4 to 7 days
-ADV: effectiveness for sterilizing porous materials, large equipment, and materials sensitive to heat or moisture
-DISADV: special equipment needed, length of sterilization and ventilation time necessary to reduce tissue toxicity
-if sterilization with gas is not available and absolute sterility is not required, chemical disinfection can be performed
67
Settings for steam sterilization may vary:
Tm and time
* 121°C at 15 psi, for 20 minutes
* 125°C at 20 psi for 16 minutes
* 134°Cat 32 psi for 3.5 minutes
68
When is it possibility for organisms to enter sterilization bags increased?
6 months after sterilization the possibility of organisms entering sterilization bags increases
all sterilized items should be labeled with an expiration date that is no longer than 6 to 12 months in the future
69
Solutions acceptable for disinfecting instruments for surgery include:
* glutaraldehyde
* Iodophors
* chlorine compounds
* formaldehyde 1
70
Rules for disinfection/sterilization of equipment:
* Alcohols are not suitable for general disinfection because they evaporate too rapidly
* they can be used to disinfect local anesthetic cartridges
* The agent must be properly reformulated and discarded periodically as specified by the manufacturer
* Instruments must remain in contact with the solution for the designated period, and no new contaminated instruments should be added to the solution during that time
* All instruments must be washed free of blood or other visible material before being placed in the solution
* After disinfection the instruments must be rinsed free of chemicals and used within a short time
•2 layers of sterile towels or waterproof paper
should be placed with the sterile or disinfected instruments
•If the towels become saturated, they can allow bacteria from the unsterile under surface to wick up to the sterile instruments
-Any surface that a patient or patient’s secretions contact is a potential carrier of infectious organisms
71
The operatory room can be disinfected in two basic ways:
* The first is to wipe all surfaces with a hospital-grade disinfectant solution
* The second is to cover with protective shields that are changed between each patient
72
Two basic types of aseptic technique:
1. the clean technique
•protectthe staff and other patients from a particular patient
•protect the patient from pathogens that the staff may harbour
-When using a clean technique, the staff may wear
•clean street clothing covered by long-sleeved laboratory coats
•a uniform (e.g. surgical scrubs) with no further covering or covered by a long-sleeved surgical gown
-Oral surgeon should wear sterile gloves whenever they are providing invasive medical care
•When the clean technique is used hands may be washed with antiseptic soap and dried on a disposable towel before gloving
•Gloves should be sterile and put on using an appropriate technique to maintain sterility of the external surfaces
•In general eye protection should be worn when blood or saliva are dispersed, such as when high-speed cutting equipment is used
-A face-mask and hair coverage should be used whenever aerosols are created or a surgical wound is to be made
-During an oral surgical procedure, only sterile water or sterile saline solution should be used to irrigate open wounds
•A disposable injection syringe, a reusable bulb syringe, or an irrigation pump connected to a bag of intravenous solution can be used to deliver irrigation
2. the sterile technique
- purpose: to minimize the number of organisms that enter wounds created by the surgeon
73
The most common risk for transmission of disease from infected patients to the staff is by:
Sharps injuries can be prevented by:
accidental needle sticks or scalpel lacerations
* using the local anesthetic needle to scoop up the sheath after use
* using an instrument such as a hemostat to hold cover while resheathing the needle,
* or using automatically resheathing needles
- never to apply or remove a blade from a scalpel handle without an instrument and disposing of used blades, needles, and other sharp disposable items into rigid, well-marked container specially designed for contaminated sharp objects
- For environmental protection, contaminated supplies should be discarded in properly labeled bags and removed by a reputable hazardous waste management company
74
The term flap, indicates a section of soft tissue that:
Soft tissue flaps are frequently used in:
1. is designed by a surgical incision,
2. carries its own blood supply,
3. allows surgical access to underlying tissues,
4. can be replaced in the original position, and
5. maintained with sutures
Soft tissue flaps are frequently used in
•oral surgical,
•periodontal, and
•endodontic procedures
-to gain access to underlying tooth and bone structures
-to provide adequate exposure and promote proper healing
75
*SOS*
When the flap is designed, the base of the flap must be:
BROADER THAN THE FREE MARGIN to preserve adequate blood supply otherwise it can lead to flap necrosis
- is required to provide necessary visualization of the area
- adequate access must also exist
- the flap must be held out of the operative field by a retractor that must rest on intact bone
- must be enough flap reflection to permit the retractor to hold the flap without tension
76
*SOS*
For an envelope flap to be of adequate size, the length of the flap in the anteroposterior dimension extends:
2 ANTERIOR TEETH and 1 POSTERIOR TOOTH
77
Full-thickness mucoperiosteal flaps includes:
•the surface mucosa
•the sub-mucosa
•the periosteum (is the primary tissue responsible for bone healing)
-replacement of the periosteum in its original position
the bone healing process is more faster
•When a full-thickness flap is elevated, less bleeding is produced because the tissue plane between bone and periosteum is relatively avascular
78
Types of Mucoperiosteal Flaps:
The most common incision is the:
If the patient is edentulous:
sulcular incision
If the patient is edentulous the envelope incision is usually made along the scar at the crest of the ridge
79
If the sulcular incision has a vertical-releasing incision, it is a:
An incision that is used occasionally to approach the root apex is a:
three-cornered flap with corners
•at the posterior end of the envelope incision
•at the inferior aspect of the vertical incision
•at the superior aspect of the vertical-releasing incision
semi-lunar incision
80
Sutures:
* hold the flap in position and approximate the opposing wound edges
* aid in hemostasis
* hold a soft tissue flap over bone
81
The armamentarium for suturing includes:
* needle holder
* suture needle
* suture material
82
When passing the needle through tissue, the needle should enter:
If the needle passes through tissue obliquely, the suture then:
the needle should enter the surface of the mucosa at the right angle, to make the smallest possible hole in the mucosal flap
If the needle passes through tissue obliquely, the suture will tear through the surface layers of the flap when the suture knot is tied, which results in greater injury to soft tissue
83
The term excessive means that:
the force will probably result in a fracture of bone, a tooth root or both
84
Young patients have bone that is:
Older patients have bone that is:
young patients have bone that is more elastic and more likely to expand with controlled force
older patients usually have denser, more highly calcified bone that is less likely to provide adequate expansion during luxation of the tooth
Patient who has very short clinical crowns with evidence of severe attrition as a result of bruxism.
These teeth are surrounded by dense, thick bone with strong periodontal ligament attachments
85
Hypercementosis:
has formed a large bulbous root difficult to remove through the available tooth socket opening
great force used to expand the bone may result in fracture of the root or the buccocortical bone
86
Open extraction:
can by pass the need for extensive force and result in a quicker, less traumatic extraction
The technique is essentially the same for single-rooted teeth that have resisted attempts at closed extraction or that have fractured at the cervical line and, therefore, exist only as a root
options:
1. the surgeon may attempt to reseat the extraction forceps under direct visualization
2. grasp a bit of buccal bone under the buccal beak of the forceps
3. use the straight elevator, pushing it down the periodontal ligament space of the tooth
4. surgical bone removal
In a vertical dimension, bone should be removed approximately one half to two thirds the length of the tooth root. This amount of bone removal sufficiently reduces the amount of force necessary to displace the tooth and makes removal relatively easy
If the tooth is still difficult to extract after the removal of bone, a purchase point can be made in the root with the bur at the most apical portion of the area of bone removal for the insertion of the elevator
-If the closed technique is unsuccessful, the surgeon should switch, without delay, to the open technique.
87
If the crown of the tooth remains intact:
if the crown portion of the tooth is missing and only the roots remain:
the crown portion is sectioned in such a way as to make easier the removal of roots
the goal is to separate the roots to make them easier to elevate
88
*SOS*
If the lower molar is difficult to extract it can be sectioned into single –rooted teeth with a drill into:
MESIAL AND DISTAL HALVES
89
An alternative method for removing the lower first molar is to:
section the mesial root from the tooth and convert the molar into two single-rooted teeth
The crown with the distal root intact is extracted with lower molar forceps
The remaining mesial root is elevated from the socket with a Cryer elevator
The elevator is inserted into the empty tooth socket and rotated, using the wheel-and-axle principle
90
If the crown of the maxillary molar is intact or its missing the:
2 buccal roots are sectioned from the tooth and the crown is removed along with the palatal root
91
Whichever technique is chosen for removal of Root Fragments and Tips, two requirements for extraction are critically important:
(1) excellent light and
| (2) excellent suction, preferably with a small diameter suction tip
92
If the irrigation-suction technique is unsuccessful:
remove the root apex from the socket with a root tip pick
The root tip pick is inserted into the periodontal ligament space, and the root is removed out of the socket
93
No excessive apical force or excessive lateral force should be applied to the root tip
Excessive apical force could result in:
Excessive lateral force could result in:
Excessive apical force could result in displacement of the root tip into other anatomic locations such as the maxillary sinus
Excessive lateral force could result in the bending or fracture of the delicate end of the root tip pick
94
When a larger portion of the tooth root is left behind after extraction of the tooth, what do you use?
small straight elevator used as a wedge to displace the tooth in the occlusal direction
95
Open-window technique =
is indicated when:
A modification of the open technique just described can be performed to deliver the root fragment without excessive removal of the buccal plate overlying the tooth
is indicated when bucco-crestal bone must be maintained
96
Three conditions should exist for a tooth root to be left in the alveolar process:
* the root fragment should be small, usually no more than 4 to 5 mm in length
* the root must be deeply embedded in bone and not superficial
* the tooth involved must not be infected and there must be no radiolucency around the root apex
97
*SOS*
Extraction Sequencing if multiple extraction is needed:
which teeth should be extracted first and why?
which teeth should be extracted last?
DISADV:
Maxillary teeth should usually be removed first b/c:
a) an infiltration anesthetic for maxillary teeth has a more rapid onset and also disappears more rapidly
b) during the extraction process, debris such as portions of amalgams, fractured crowns, and bone chips may fall into the empty sockets of the lower teeth if the mandibular surgery is performed first
(ALL)
DISADV: if hemorrhage is not controlled, it may interfere with visualization during mandibular surgery
The CANINE, should be extracted LAST
Most posterior teeth are extracted first
1st maxillary posterior teeth
2nd maxillary anterior teeth, leaving the canine
3rd maxillary canine
4th mandibular posterior teeth
5th mandibular anterior teeth, leaving the canine
6th MANDIBULAR CANINE (3rd from the lower ones)
-Teeth adjacent to the mandibular canine are extracted first
98
The first step in removing a single tooth is to:
loosen the soft tissue attachment from around the tooth
99
The periosteal elevator is used to:
reflect labial soft tissue just to the crest of labioalveolar bone
100
Rongeur forceps are used to:
remove only bone that is sharp and protrudes above re-approximated soft tissue
101
When an implant may be placed in the future, care should be taken to not:
overly reduce the alveolar width with compression
102
Postoperative instructions should explain:
The postoperative instructions should describe the:
* what the patient is likely to experience
* why these phenomena occur
* how to manage and control typical postoperative situations
- The instructions should be given to the patient orally and also written or printed on paper, in easily understood terms
- The postoperative instructions should describe the most common complications and they should also include a telephone number of the doctor for an emergency
103
*SOS*
Patients should be cautioned to avoid things that may aggravate the bleeding:
-Patients who smoke should be encouraged to avoid smoking for the first 12 hours
•TOBACCO SMOKE and nicotine interfere with wound healing
-The patient should also be told DON'T SUCK A STRAW when drinking because this also creates negative pressure
-The patient SHOULDN'T SPIT during the first 12 hours after surgery due to negative pressure (swallow their saliva instead of spitting it out)
-no strenuous exercise
104
Indications for a return visit:
* prolonged oozing
* bright red bleeding
* large clots in the patient's mouth
105
Arterial bleeds that cannot be controlled with local measures should be treated with:
ligation or electrocautery
106
The patient should be told to take analgesic post operatively to:
goal of analgesic medication:
The first dose of analgesic medication should be taken when?
to prevent initial discomfort when the effect of the local anesthetic disappears
the goal of analgesic medication is management of pain and not elimination of all discomfort
-The surgeon should also take care to advise the patient that
•The first dose of analgesic medication should be taken before the effects of the local anesthetic subside
107
The three characteristics of the pain that occur after routine tooth extraction:
(1) The pain is usually not severe and can be managed in most patients with mild analgesics
(2) The peak pain experience occurs about 12 hours after the extraction and diminishes rapidly after that
(3) Significant pain from extraction rarely persists longer than 2 days after surgery
108
Diet after routine tooth extraction:
- The patient must have an adequate intake of fluids, usually at least 2 liters(L), during the first 24 hours
- The fluids can be juices, milk, water
- Food in the first 12 hours should be soft and cool
- ex: ice cream and milkshakes
109
They should avoid brushing the teeth immediately adjacent to the extraction site to prevent:
* a new bleeding episode
* avoid disturbing sutures
* avoid inducing more pain
110
The next day, patients should begin:
gentle rinses with oral mouth as CHX
-rinsing three to four times a day for approximately 1 week after surgery may result in more rapid healing
111
*SOS*
Swelling usually reaches its maximum 36 to 48 hours after the surgical procedure, may be an indication of:
INDICATION OF INFECTION (rather than renewed post surgical edema)
-a moderate amount of swelling is a normal and healthy reaction of tissue to the trauma of surgery
112
*SOS*
Ice packs after routine tooth extraction:
-Ice SHOULDN'T BE PLACED DIRECTLY ON THE SKIN, but preferably a layer of dry cloth should be placed between the ice container and the tissue to prevent superficial tissue damage
-The ice bag should be kept on the local area for 20 minutes and then kept off for 20 minutes, for 12 to 24 hours
•On the second postoperative day, neither ice nor heat should be applied to the face
113
Trismus can result from:
from extraction of teeth, administration of a mandibular block, or both, trauma, multiple injections of the local anesthetic
-resulting inflammation involving the muscles of mastication
114
Ecchymosis =
usually seen in:
onset:
resolves:
= blood in the submucosal or subcutaneous tissues
- usually seen in older patients because of their decreased tissue tone, increased capillary fragility, and weaker intercellular attachments
- is not dangerous and does not increase pain or infection
- onset: 2 to 4 days after surgery and usually resolves within 7 to 10 days
115
Sutures should be removed as needed in:
1 week
116
The most likely reasons for an earlier visit are:
* prolonged bleeding
* pain that is not responsive to the prescribed medication
* suspected infection
117
How can it be assumed that the patient has developed an infection?
swelling with surface redness, fever, pain or all of these symptoms on the third postoperative day or later
118
Elements of an Operative Notes:
* Date
* Patient name and identification
* Diagnosis of problem to be managed surgically
* Review of medical history, medications, and vital signs
* Oral examination
* Anesthesia(amount used)
* Procedure (including description of surgery and complications)
* Discharge instructions
* Medications prescribed and their amounts (or attach copy of prescription)
* Need for follow-up appointment
* Signature of doctor
119
In planning a surgical procedure, the first step is always:
a review of the patient's medical history
2nd: obtaining adequate images
120
Visualization and access to the operative field requires adequate :
* light
* soft tissue retraction and reflection
* suction
121
Controlled force is of paramount importance, this means:
"finesse," not "force“
122
Prevention of soft tissue injuries:
1. Pay strict attention to soft tissue injuries
2. Develop adequate –size flaps
3. Use minimal force for retraction of soft tissue
123
Tear of a Mucosal Flap:
results from:
prevention:
- most frequent
- results from an initially inadequately sized envelope flap
- Prevention of this complication is threefold:
(1) creating adequately sized flaps to prevent excess tension on the flap
(2) using controlled amounts of retraction force on flap
(3) creating releasing incision which indicated
124
Stretch or Abrasion:
result from:
treatment:
- result from the rotating shank of the bur rubbing on soft tissue or from a metal retractor coming in contact with soft tissue
- little treatment is possible other than keeping the area clean with regular oral rinsing
- heal in 4 to 7 days (depending on the depth of damage) without scarring
- antibiotic ointment if the abrasion develops on skin
125
Prevention of Root Fracture and Displacement:
1. Always consider the possibility of root fracture
2. Use surgical (open) extraction if high probability of fracture exists
3. Do not use strong apical force on a broken root
126
Tooth lost into the Pharynx:
patient should be turned toward the dentist and placed into a position with the mouth facing the floor as much as possible
-patient should be encouraged to cough and spit the tooth out onto the floor
127
The most likely places for bone fractures are:
* the buccal cortical plate over the maxillary canine
* the buccal cortical plate over maxillary molars
* the portions of the floor of the maxillary sinus that are associated with maxillary molars
* the maxillary tuberosity
* labial bone over mandibular incisors
128
Prevention of fractures of large portions of the cortical plate depends on:
preoperative radiographic and clinical assessments
129
If the mental nerve is injured the patient will experience:
paresthesia or anesthesia of the lip and chin
130
If the injury is the result of flap reflection or manipulation:
normal sensation usually returns in a few days to a few weeks
131
If the mental nerve is sectioned at its exit from the mental foramen or torn along its course it is likely that:
mental nerve function will not return, and the patient will have a permanent state of anesthesia
132
The most common place of injury of the inferior alveolar nerve is:
is the area of the mandibular third molar
133
If the patient complains of pain in the TMJ area immediately after the extraction procedure:
Prevention of Injury to Temporomandibular Joint:
the surgeon should recommend the use of moist heat, resting the jaw, a soft diet and 600 to 800 mg of ibuprofen every 4 hours for several days
Prevention of Injury to Temporomandibular Joint
1. Support the mandible during extraction
2. Do not force open the mouth too widely
134
The diagnosis of an oroantral communication can be made in several ways:
The first is to examine the tooth once it is removed
-if a section of bone attaches to the root ends of the tooth, the surgeon should assume that a communication between the sinus and mouth exists
Second is using the nose blowing test to confirm the presence of a communication
- if the communication is small, no additional surgical treatment is necessary
- if opening is large (7 mm or larger), the surgeon should consider having the sinus communication repaired with a flap procedure
135
The status of therapeutic anticoagulation is measured by using the:
international normalized ratio (INR)
-Normal anticoagulated status for most medical indications has an INR of 2.0 to 3.0
136
Prevention of wound dehincence:
=
* Use aseptic technique
* Perform atraumatic surgery
* Close the incision over intact bone
* Suture without tension
= separation of wound edges
137
Dry socket:
The pain develops on the third or fourth day after removal of the tooth
On examination the tooth socket appears to be empty with a partially or completely lost blood clot and some bony surfaces of the socket are exposed
The area of the socket has a bad odor, and the patient frequently complains of a foul taste
The socket should not be curetted down to bare bone because this increases the amount of exposed bone and the pain
The socket is gently suctioned of all excess saline, and a small strip of iodoform gauze soaked in or coated with the medication is inserted into the socket with a small tag of gauze left trailing out of the wound
The medication contains the following principal ingredients:
•eugenol which obtunds the pain from the bone tissue
•a topical anesthetic such as benzocaine
•a carrying vehicle such as balsam of Peru
138
*SOS*
Fractured mandibular molar roots that are being removed with apical pressures may be displaced into the:
submandibular space
